Experience with end-of-life practice at a university hospital.

Campbell ML, Frank RR; Critical Care Medicine 1997;25:197-202.

[ see abstract below ]

One of the most neglected areas of medicine is decision-making for and care of the terminally ill. Appropriate and humane withdrawal of aggressive and invasive medical support technologies allows patients with irreversible fatal disease to spend their final days in dignity, close to their loved ones, with all medical measures geared toward their comfort. In addition, cessation of futile care in a high intensity unit saves a large amount of unnecessary cost.

In the January issue of Critical Care Medicine, an Advanced Practice Nurse, Ms Margaret Campbell, and a member of the Department of Medicine at Wayne State University, Dr Robert Frank, describe the service provided by the Comprehensive Supportive Care Team at Detroit Receiving Hospital. The hospital is a level 1 trauma center in which more than 30% of the beds are dedicated to intensive care.

The patient population is largely indigent, with little close family or community support, and most enter through the emergency department without a primary caregiver. In this challenging milieu, the Comprehensive Supportive Care Team has cared for more than 1,400 dying patients and their families since 1986.

Patients who are not expected to survive hospitalization are referred to Ms Campbell, an Advanced Practice Nurse, who works in collaboration with a physician. In more than half the cases, the decision to limit life support is made by a substituted judgement, i.e. a family member (patient surrogate) infers the decision the patient would have made if capable, based upon their knowledge of the patient's wishes.

In about 20% of cases, a best-interest decision is made, where the surrogate has no knowledge of the patient's wishes. In only about 17% of cases are advanced directives available, and even then almost 90% are verbal rather than written.

Once the patient is transferred to the Comprehensive Supportive Care Team, the patient is moved from the intensive care unit (ICU) to a general ward and continued care, planning, and family interaction are coordinated by the team until the patient's death or discharge from hospital.

About 65% of the patients undergo terminal ventilatory weaning, and about 20% have artificial nutrition withdrawn, as the mode of discontinuation of life-sustaining therapy. On average, the Therapeutic Intervention Severity Score is halved and the cumulative cost savings both from technology and ICU bed cost was over a half a million dollars in the 1995 fiscal year alone.

The advantages of the Comprehensive Supportive Care Team cited by the authors are several. By moving the patient out of the ICU, patients have increased privacy and comfort, and medical care becomes directed toward the patient's responses (e.g. pain, dyspnea) rather than the disease. The Advanced Care Nurse and collaborative physicians have equal responsibility in dealing with the patient and family.

All of us who are involved in the care of terminally ill patients, whether in the operating room or, more commonly, ICU, should read this article. The Comprehensive Supportive Care Team, conceived under such adverse circumstances in Detroit, should be a role model for a similar approach at our own hospitals.



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